EM-SERC Sim Template



Section 1: Case SummaryScenario Title:Suspected Coronavirus (COVID-19) w Respiratory FailureKeywords:Infectious disease, provider safety, airway managementBrief Description of Case:Case designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a critically ill coronavirus patient from triage through to intubation.Goals and ObjectivesEducational Goal:Practice personal and team safety while assessing and providing care to a patient with a potentially airborne respiratory illness requiring full personal protective equipment.Objectives:(Medical and CRM)Effective team communication from triage to intubation of a high-risk coronavirus patientMitigating exposure of HCPs, patients, by appropriately isolating high risk patients in negative pressure roomMitigating personal risk by utilizing the appropriate donning/doffing of PPE?Conducting effective high acuity clinical care (i.e. intubation) in space and personnel limited negative pressure room effectivelyInfection Prevention and Control Objectives(See Appendix C for details)The guidelines for the novel coronavirus are changing frequently as we receive new information about the virus. Infection prevention and control (IPAC) considerations also vary between institutions. Please review the most up-to-date guidelines and discuss with your IPAC team before running the simulation.EPAs Assessed:Not for routine educationLearners, Setting and PersonnelTarget Learners:? Junior Learners? Senior Learners? Staff? Physicians? Nurses? RTs? Inter-professional? Other Learners: Infection Prevention and Control TeamLocation:? Sim Lab? In Situ? Other: Recommended Number of Facilitators:Instructors: 1Confederates: 1Sim Techs: 1Scenario DevelopmentDate of Development:January 26, 2020Scenario Developer(s):Dr. Alia Dharamsi, Dr. SooJin Yi, Dr. Kate HaymanAffiliations/Institutions(s):University of TorontoContact E-mail:alia.dharamsi@Twitter:Please credit the authors: @alia_dh @soojinder @hayman_kate when posting about use of this case onsocial mediaRevised By:Version Number:1Section 2A: Initial Patient InformationPatient ChartPatient Name: Ms. Grace YiAge: 35Gender: FWeight: 60kgPresenting complaint: Shortness of breath, cough, feverTemp: 39.2HR: 140BP: 100/60RR: 22O2Sat: 90%FiO2: RACap glucose: 7.1GCS: 15Triage note: 35-year-old woman became febrile last night with coryza and woke up acutely short of breath with productive cough, rhinorrhea, and a subjective fever. She screens positive for potential coronavirus exposure due to fever, respiratory symptoms and a high-risk travel history.Allergies: NonePast Medical History: NoneCurrent Medications: IbuprofenAcetaminophenSection 2B: Extra Patient InformationA. Further HistoryInclude any relevant history not included in triage note above. What information will only be given to learners if they ask? Who will provide this information (mannequin’s voice, confederate, SP, etc.)?History per triage note. Additional travel history given.B. Physical ExamList any pertinent positive and negative findingsCardio: TachycardiaNeuro: NilResp: Crepitus and expiratory wheezes bilaterally, productive coughHead & Neck: CoryzaAbdo: NilMSK/skin: FlushedOther: NilSection 3: Technical Requirements/Room VisionA. Patient? Mannequin: Adult ? Standardized Patient? Task Trainer? HybridB. Special Equipment RequiredNegative pressure/isolation room Airborne PPE for all involvedDonning/doffing area/ ante room (either actual ante room if done in negative pressure room, or tape on the floor to designate mock ante room)C. Required MedicationsRoutine drugs for intubation, sedation, paralysisD. MoulageAerosolizer for creating secretions from mannequin Glo Dust on mannequin’s face and upper body/arms See here for further instructions: to simulationist Roger ChowNB: this is a live document and may undergo updatesE. Monitors at Case Onset? Patient on monitor with vitals displayed? Patient not yet on monitorF. Patient Reactions and ExamInclude any relevant physical exam findings that require mannequin programming or cues from patient (e.g. – abnormal breath sounds, moaning when RUQ palpated, etc.) May be helpful to frame in ABCDE format.A - URTI, cough, patent airwayB - Bilateral crepitus, decreased air entry bilaterally due to shortness of breath, scant expiratory wheeze, no pedal edema or calf tendernessC - Tachycardic and febrile, D - Moving x4, GCS 15Section 4: Confederates and Standardized PatientsConfederate and Standardized Patient Roles and ScriptsRoleDescription of role, expected behavior, and key moments to intervene/prompt learners. Include any script required (including conveying patient information if patient is unable)StandardizedPatientStandardized patient (SP) is to arrive at triage coughing and febrile, with rapid respiratory rate and short of breath. SP is to describe travel history: was in mainland China last week for business. Visited Hubei Province. She returned two days ago and became ill 24 hours after landing in Canada. SP is to be too weak to walk Once SP is placed into negative pressure room, SP replaced with mannequinSection 5: Scenario ProgressionScenario States, Modifiers and TriggersPatient State/VitalsPatient StatusLearner Actions, Modifiers & Triggers to Move to Next State Facilitator Notes1. TriageRhythm: Sinus tachHR: 140BP: 100/60RR: 22O2SAT: 90%T: 39.2oC GCS: 15 Short of breath, coughing, febrileDescribes travel historyExpected Learner Actions FORMCHECKBOX Obtain vital signs FORMCHECKBOX Apply PPE to patient FORMCHECKBOX Move to neg pressure room FORMCHECKBOX Triage RN to contact MD and bedside team with details FORMCHECKBOX Call IPAC (or local equivalent) FORMCHECKBOX HCPs don appropriate PPEModifiers Changes to patient condition based on learner actionTriggers For progression to next state- Move patient to neg pressure room, handover to bedside team2. Initial AssessmentRR: 28O2SAT: 84%Mannequin replaces SPExpected Learner Actions FORMCHECKBOX IV Access, monitors FORMCHECKBOX Apply O2 by NRB mask FORMCHECKBOX Portable Xray, Labs, ECG FORMCHECKBOX Point of care ultrasound FORMCHECKBOX Call RT FORMCHECKBOX IV Bolus, consider antibiotics (empiric), swabs for flu and coronavirus, septic workupModifiers- O2Sat increases to 90% with supplemental O2Triggers- All action complete3. IntubationRR: 30O2SAT: 86% NRBPatient becoming more hypoxic, agitatedExpected Learner Actions FORMCHECKBOX Prepare for intubation (push dose pressors, equipment, personnel, medications) FORMCHECKBOX IntubateModifiersTriggers- Successful intubationNot anticipated to be difficult airway, easy intubation4. DispositionRR: 14O2SAT: 92% (Vented 100% FiO2)Expected Learner Actions FORMCHECKBOX Continue bolus fluids FORMCHECKBOX Routine post-intubation care FORMCHECKBOX Sedation FORMCHECKBOX Call ICUModifiersTriggers- Handover to ICU5. Exposure ManagementTriage nurse to ask team lead what they should do now that they are exposed to potential case FORMCHECKBOX Identify potential exposed persons, nature of exposure FORMCHECKBOX Liaise with IPAC (or local equivalent) FORMCHECKBOX Isolate potential exposed persons until further IPAC instructionModifiersTriggers- All actions complete6. Aerosol Assessment (optional) FORMCHECKBOX Use black light to see where Glo Germ lights up on care providers and equipment to assess areas of contamination or PPE breachesModifiersTriggers- All actions completeSee Appendix C for details on setting up Glo Germ AerosolizerAppendix A: Laboratory ResultsNoneAppendix B: ECGs, X-rays, Ultrasounds and PicturesPaste in any auxiliary files required for running the session. Don’t forget to include their source so you can find them later!X-ray: Case courtesy of Prof Frank Gaillard, . : : C: Facilitator Cheat Sheet & Debriefing TipsIn Situ Simulation for Quality ImprovementThis case has drawn interest from multiple teams at our site, including teams that are not familiar with the general objectives and principles of in situ simulation. For some observers, this was their first ever experience with in situ medical simulation. A review of basic objectives of in situ simulation is critical to ensure that all participants understand the goals of the exercise. We suggest hosting a pre-brief and a debrief with the full team and observers, making explicit that in situ simulation is meant to review the current state of our practice, identify latent safety threats, and move towards best practice. Our goal is to unmask systems factors that contribute to any breaches in best practice and address them. At our institution, this has led to changes in equipment preparation, standardized tools for communication in isolation rooms, and further educational sessions for staff.Infection Prevention and Control ConsiderationsThe guidelines for the novel coronavirus are changing frequently as we receive new information about the virus. Infection prevention control (IPAC) considerations also vary between institutions. Please review the most up-to-date guidelines and discuss with your IPAC team before running the simulation.Below are some suggested considerations for review.Should a “code resuscitation” be called for these patients, or should the team be kept smaller to mitigate risk to healthcare team/exposure?What personal protective equipment (PPE) must providers wear? RT/Intubating MD?What mask/PPE should patients be wearing if high risk and being transferred (i.e. from triage to room, to imaging)Who activates IPAC and when?What swabs/investigations need to be sent?What interventions should be avoided (BiPaP, nebs…)?What are next steps for staff members who may have been inadvertently exposed?What are the appropriate decontamination measures for equipment (ultrasound)? Should these pieces of equipment not be brought into the room?How will we bring equipment (medical supplies, x-ray machine) through the ante room?How will the team in the isolation room communicate with the team outside the room?Props for 2019-nCoV In-situ Simulations: The Aerosolized SneezerCredit to simulationist Roger Chow(Please note this prop is in early stages of development and pressed into action because of time. So as is there’s quite a bit of fluid leakage that happens at the back of the manikin’s head and onto the stretcher)The most up to date version can be found at: Bernoulli’s Principle, this prop incorporates a high gas flow and a fluid source.The gas source is from the wall outlet so you need high pressure hoses (air or O2) to a check valve for controlling flow of gas. I used a spring-loaded check valve reclaimed from a Bird ventilator, but you can find something at the hardware store (Canadian Tire, Home Depot, etc.) From my check valve I attached an O2 nipple to connect suction tubing (2 for a greater length). From the suction tubing add a “T” connecter. This is where the fluid source comes in at a 90-degree angle. The fluid source is from an IV bag with IV tubing and a disposable pressure infuser, so fluid can be primed up to the point of the “T” connecter. From the remaining port of the “T” connecter, attach a large bore flexible tubing about 7” long. This will be the output of the aerosolized spray.For the spray to come out of the manikin’s nose, remove the manikins face and find a direct path to the inside of a nare. You will need to cut a passage into the manikin to incorporate the prop. To hide the tubing with the gas and liquid source, lay a blue pad underneath them and then cover with another blue pad. This doubles as camouflage and absorbs the extra fluid from the leaking. Open and close the valve to create the wet sneeze. Re-prime the line with fluid so it’s at the point of the “T” connector.I would not cut into my manikin if it’s still under warranty. I did it on a Laerdal ALS manikin and a 15 year old SimMan. Post manikin cut for the prop insertion, you are still able bag mask ventilate the manikin. The path of least resistance is still to the “lungs”Glo Germ: available on Amazon2 of the same wigs2 of the same tee shirtsReferences1. . 3. ................
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